Thursday, December 31, 2015

I arrived in Tirana, Albania, on a Sunday evening in late August, on a flight from Istanbul. The sun had set while the plane was midflight, and as we landed in the dark, images of fading light still filled my mind. The man next to me, a young, red-haired American wearing a straw hat, asked me if I knew how to get into town from the airport. I shook my head, put the book I had been reading into my backpack, got up, lifted my suitcase out of the overhead compartment and stood waiting in the aisle for the door up ahead to open.

That book was the reason I had come. It was called "Do No Harm," and it was written by the British neurosurgeon Henry Marsh. His job is to slice into the brain, the most complex structure we know of in the universe, where everything that makes us human is contained, and the contrast between the extremely sophisticated and the extremely primitive — all of that work with knives, drills and saws — fascinated me deeply. I had sent Marsh an email, asking if I might meet him in London to watch him operate. He wrote a cordial reply saying that he seldom worked there now, but he was sure something could be arranged. In passing, he mentioned that he would be operating in Albania in August and in Nepal in September, and I asked hesitantly whether I could join him in Albania.

Now I was here.

Tense and troubled, I stepped out of the door of the airplane, having no idea what lay ahead. I knew as little about Albania as I did about brain surgery. The air was warm and stagnant, the darkness dense. A bus was waiting with its engine running. Most of the passengers were silent, and the few who chatted with one another spoke a language I didn't know. It struck me that 25 years ago, when this was among the last remaining Communist states in Europe, I would not have been allowed to enter; then, the country was closed to the outside world, almost like North Korea today. Now the immigration officer barely glanced at my passport before stamping it. She dully handed it back to me, and I entered Albania.

In the arrivals hall, a young man dressed in a bright white shirt came over.

"Welcome to Albania, Mr. Knausgaard. My name is Geldon Fejzo. Mr. Marsh and Professor Petrela are waiting for you at the hotel. The car is right outside."

The car was a black Mercedes, with leather seats and air conditioning. It turned out that Fejzo had just completed his medical training as a neurosurgeon. He was 31 and had studied in Florence. He had also worked as an intern for a few months at a London hospital with Mr. Marsh, as he called him, in the manner long preferred by British surgeons.

"What is he like?" I asked.

"Mr. Marsh?"

I nodded.

"He's a fantastic person," Fejzo said.

Marsh was in Tirana to demonstrate a surgical procedure he helped pioneer, called awake craniotomy, that had never been performed in Albania. The procedure is used to remove a kind of brain tumor that looks just like the brain itself. Such tumors are most common in young people, and there is no cure for them. Without surgery, 50 percent of patients die within five years; 80 percent within 10 years. An operation prolongs their lives by 10 to 20 years, sometimes more. In order for the surgeon to be able to distinguish between tumor and healthy brain tissue, the patient is kept awake throughout the operation, and during the procedure the brain is stimulated with an electric probe, so that the surgeon can see if and how the patient reacts. The team in Albania had been preparing for six months and had selected two cases that were particularly well suited to demonstrating the method.

With a growing number of American women choosing to give birth at home or in birthing centers, debate is intensifying over an important question: How safe is it to have a baby outside a hospital?

A study published Wednesday in The New England Journal of Medicine provides some of the clearest information on the subject to date.

The study analyzed nearly 80,000 pregnancies in Oregon, and found that when women had planned out-of-hospital deliveries, the probability of the baby dying during the birth process or in the first month after — though slight — was 2.4 times as likely as women who had planned hospital deliveries.

Out-of-hospital births also carried greater risk of neonatal seizures, and increased the chances that newborn babies would need ventilators or mothers would need blood transfusions.

On the other hand, out-of-hospital births were far less likely to involve cesarean sections — 5.3 percent compared with 24.7 percent in a hospital. They also involved fewer interventions to augment labor, and mothers had fewer lacerations.

Tuesday, December 29, 2015

The narrow, inscrutable zone between undeniably still here and unequivocally gone includes a range of states that look like life but may not be: a beating heart, a functioning digestive system, even moving fingers and toes. Death is less a moment than a process, a gradual drift out of existence as essential functions switch off, be it rapidly or one by one.

It was exactly midnight when Colleen Burns was wheeled into the operating room at St. Joseph's Hospital Health Center in Syracuse, N.Y. She had been deep in a coma for several days after overdosing on a toxic cocktail of drugs. Scans of electrical activity in her brain were poor, and oxygen didn't seem to be flowing. Burns was brain dead, her family was told; if they wanted to donate her organs, now was the time to do it.

Monday, December 28, 2015

A spoof paper concocted by Science reveals little or no scrutiny at many open-access journals.

On 4 July, good news arrived in the inbox of Ocorrafoo Cobange, a biologist at the Wassee Institute of Medicine in Asmara. It was the official letter of acceptance for a paper he had submitted 2 months earlier to the Journal of Natural Pharmaceuticals, describing the anticancer properties of a chemical that Cobange had extracted from a lichen.

In fact, it should have been promptly rejected. Any reviewer with more than a high-school knowledge of chemistry and the ability to understand a basic data plot should have spotted the paper's short-comings immediately. Its experiments are so hopelessly flawed that the results are meaningless.

I know because I wrote the paper. Ocorrafoo Cobange does not exist, nor does the Wassee Institute of Medicine. Over the past 10 months, I have submitted 304 versions of the wonder drug paper to open-access journals. More than half of the journals accepted the paper, failing to notice its fatal flaws. Beyond that headline result, the data from this sting operation reveal the contours of an emerging Wild West in academic publishing.

"Slim by Chocolate!" the headlines blared. A team of German researchers had found that people on a low-carb diet lost weight 10 percent faster if they ate a chocolate bar every day. It made the front page of Bild, Europe's largest daily newspaper, just beneath their update about the Germanwings crash. From there, it ricocheted around the internet and beyond, making news in more than 20 countries and half a dozen languages. It was discussed on television news shows. It appeared in glossy print, most recently in the June issue of Shapemagazine ("Why You Must Eat Chocolate Daily," page 128). Not only does chocolate accelerate weight loss, the study found, but it leads to healthier cholesterol levels and overall increased well-being. The Bild story quotes the study's lead author, Johannes Bohannon, Ph.D., research director of the Institute of Diet and Health: "The best part is you can buy chocolate everywhere."

I am Johannes Bohannon, Ph.D. Well, actually my name is John, and I'm a journalist. I do have a Ph.D., but it's in the molecular biology of bacteria, not humans. The Institute of Diet and Health? That's nothing more than a website.

Other than those fibs, the study was 100 percent authentic. My colleagues and I recruited actual human subjects in Germany. We ran an actual clinical trial, with subjects randomly assigned to different diet regimes. And the statistically significant benefits of chocolate that we reported are based on the actual data. It was, in fact, a fairly typical study for the field of diet research. Which is to say: It was terrible science. The results are meaningless, and the health claims that the media blasted out to millions of people around the world are utterly unfounded.

Saturday, December 26, 2015

I HAD heard stories of doctors disappearing — gone, suddenly, their offices closed and no forwarding address to be found — but I never expected it from my physician of 12 years. After weeks of phoning his office, I finally reached him. He referred to himself in the third person: Dr. J. was unavailable, the practice was closing and if I wanted my medical records, I should come fetch them.
This was a man who had peered into my nose and mouth, performed prostate examinations and talked me through afflictions. He knew I was married, had children, and what I did for a living. That he would skip town without notice seemed an abrupt ending. He didn't even tell my health insurance provider that he had shut his doors.

When I arrived the next day, the doctor handed me my records and said he was closing the practice and moving it to Texas. He had not notified anyone because there were too many patients to contact, an explanation I accepted without contention, the way I had adopted so much of his advice over the years.

Everyone seems to have a health care provider they swear by — a dentist who can pull teeth without painkillers, a chiropractor who can realign spines one-handed. "My doctor is the best," I've heard countless friends say. Rarely do they say "my doctor is the worst" — partly because people don't usually stay with bad doctors very long, but also because bad doctors aren't always obvious, at least until they do something obviously bad. Like, say, suddenly closing their practice and relocating 2,000 miles away.

From the moment patients register at Memorial Sloan Kettering Cancer Center's new $300 million, state-of-the-art outpatient surgery center on the Upper East Side of Manhattan, they will be taking part in a test bed for emerging ideas in patient experience design, health care technology and data tracking.

Instead of waiting in a long line to register, patients at the new center, the Josie Robertson Surgery Center, will be handed plastic tracking badges that will broadcast their locations in real time, allowing intake coordinators to come directly to them wherever they are sitting. Inspired by modern hotel lobbies and co-working spaces, the family waiting room has semiprivate seating areas and mobile device charging stations. And for people who become antsy while their loved ones are in surgery, there is an Xbox nook for fitness activities.

Operating rooms, too, incorporate "the most advanced technology," according to marketing materials, including the latest surgical robots and "super-high-definition monitors" to display anatomical imaging.

As a young doctor working in the E.R. my capacity for compassion, and that of my colleagues, was often stretched; this was particularly the case when my patients could be said to have brought misfortune on themselves. I saw drug addicts suffering overdose, teenagers retching after self-poisoning, thieves injured through being arrested, all treated more brusquely than other theoretically more blameless patients.

I tried hard to maintain empathy, reflecting that the overdosed, self-poisoned and criminal may no more have brought their problems on themselves than those with skiing or horse-riding injuries or heart palpitations through overwork. But it's complicated: I've stitched up many slashed wrists cut not through willfulness but as a release from intense anguish; I've attended alcoholics for whom alcohol was clearly a substitute for love. I may not have always succeeded, but I always hoped that my humanity, or my professional duty to provide a high standard of care, would step in when my compassion was running low.

Compassion means "together-suffering" or "fellow-feeling" — a sense of identification we feel when imagining another's pain. The word "patient" means "sufferer," and at its most basic level the practice of medicine could be described as the attempt to ease mental and physical pain. If physicians have a surfeit of compassion — if they're too sentimental, or too thin-skinned — they do their jobs slowly, even less effectively. I've worked with colleagues like this: They don't last long in the pressurized environment of the E.R. or the primary care clinic.

Friday, December 25, 2015

Modern medicine in the Western world relies primarily on treating existing illnesses with drugs or unnecessary procedures and a quick turnaround in the doctor's office in order to treat more people. In the midst of all this hectic chaos, doctors will skim over a patient's record and medical history, get a mere glimpse into their emotional lives, and leave mental health care to the side.

But Dr. Ronald Epstein, a University of Rochester professor, wants to change the way doctors approach their patients. Suffering is seen in all corners of hospitals and medical centers — from the emotional pain of a mother who just lost an unborn baby to an older man facing a terminal illness, yet doctors often don't address it.

In a new essay published in the Journal of the American Medical Association, Epstein and a co-author, oncologist Anthony Back of the University of Washington, reviewed medical literature on the ways doctors approach suffering. They found that an approach to suffering is rarely discussed in the medical world, and that this needs to change.

"Physicians can have a pivotal role in addressing suffering if they can expand how they work with patients," the authors wrote. "Some people can do this instinctively, but most physicians need training in how to respond to suffering — yet this kind of instruction is painfully lacking."

Epstein and Back note that physicians can improve their approach by listening to the patient and learning about his/her experience. In addition to the typical "diagnosing and treating," the authors argue that doctors should also "turn toward" the patient, and recognize their suffering. They can do that by asking questions like, "What's the worst part of this for you?" Sometimes an acknowledgment that their pain is real, and that it matters to someone, is all a patient needs to open up.

Monday, December 21, 2015

A FRIEND was recently hospitalized after a bicycle accident. At one point a nursing student, together with a more senior nurse, rolled a computer on wheels into the room and asked my friend to rate her pain on a scale of 1 to 10.
She mumbled, "4 to 5." The student put 5 into the computer — and then they left, without further inquiring about, or relieving, my friend's pain.
This is not an anecdote about nurses not doing their jobs; it's an illustration of what our jobs have become in the age of electronic health records. Computer documentation in health care is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself.
Our charting, rather than our care, is increasingly what we are evaluated on. When my hospital switched to bar code scanning for medication administration, not only were the nurses on my floor rated as "red," "yellow" or "green" based on the percentage of meds we scanned, but those ratings were prominently and openly displayed on printouts left at the nurses' station.
Or consider "fall assessments," which a nurse uses to determine a patient's risk of falling while in the hospital — a problem that accounts for 11,000 deaths annually. The assessments ask about medication, mobility issues and confusion to create a "fall risk score," which then generates an appropriate menu of interventions.
A nurse could spend 10 minutes documenting a patient's fall risk, or 10 minutes trying to keep patients from falling. It seems obvious that a computer record of "fall risk" cannot in and of itself prevent falls, but completing those records is considered essential in hospitals. As a result, real fall-prevention efforts — encouraging patients to use the call light, ordering a bedside commode, having an aide do hourly check-ins — get short shrift.

Friday, December 18, 2015

Kaiser Permanente, the health system based in California that combines a nonprofit insurance plan with its own hospitals and clinics, announced Thursday that it would open its own medical school in the state in 2019.
The system's leaders said their central goal was to teach Kaiser's model of integrated care to a new generation of doctors who will be under pressure to improve health outcomes and control costs by working in teams and using technology.
"Health care is evolving at a very, very rapid pace in our country and we have a model of care that's increasingly being looked to as an answer," said Dr. Edward M. Ellison, executive medical director for the Southern California Permanente Medical Group, who is helping to oversee the medical school's creation.
Kaiser already trains about 600 medical residents in its own program, and several thousand more complete a portion of their training in it each year. But its medical school, planned for Southern California, would be one of the first run by an integrated health system without an academic partner, said Dr. George E. Thibault, president of the Josiah Macy Jr. Foundation, which encourages innovation in medical schools.
"If health care is increasingly going to take place in integrated systems," Dr. Thibault said, "a large part of the medical education experience should be what it's like to work in a system like that: the efficiencies and the processes and the ways in which patient care is benefited."
Dr. Thibault added that while Kaiser would not be the only integrated health system involved in medical education, it is "larger than any of them, has greater reach than any of them, greater resources."
Kaiser runs 38 hospitals in eight states and the District of Columbia, with 18,000 doctors working for its affiliated medical groups and more than 10 million patients, mostly in California. It receives a fixed amount for medical care per member, so there is a strong financial incentive to keep people healthy and out of the hospital, a model that Kaiser pioneered and that is now being followed around the country.
Dr. Ellison said Kaiser's use of technology, through electronic medical records and new types of telemedicine that allow patients to receive "care anywhere in a way that's safe and effective," will also be crucial to its medical school curriculum.

Can machines outperform doctors? Not yet. But in some areas of medicine, they can make the care doctors deliver better.

Humans repeatedly fail where computers — or humans behaving a little bit more like computers — can help. Even doctors, some of the smartest and best-trained professionals, can be forgetful, fallible and prone to distraction. These statistics might be disquieting for anyone scheduled for surgery: One in about 100,000 operations is on the wrong body part. In one in 10,000, a foreign object — like a surgical tool — is accidentally left inside the body.

Something as simple as a checklist — a very low tech-type of automation — can reduce such errors. For example, in a wide range of settings, surgical complications and mortality fell after implementation of a basic checklistincluding verification of patient identity and body part for surgery, confirmation of sterility of the surgical environment and equipment, and post-surgical accounting for all medical tools. Though simple procedureswould all but eliminate certain sources of infections in hospitals, thousands of patients suffer from them in American hospitals every year.

Over the course of her lifetime, Paula Schulte survived painful scoliosis that contorted her spine, a head injury that left her in a coma for weeks, and cancer that cost her part of a lung.

What she couldn't survive was 11 weeks in Florida hospitals.

Schulte, 64, was living an engaged life—staying in touch daily with her daughter, Stephanie Sinclair, a photojournalist, and taking afternoon drives with her husband, Joe. When she suffered an unexpected bout of seizures in August 2012, doctors said she would need only a short hospital stay until the drugs kicked in to remedy things.

Wednesday, December 16, 2015

A major new Commission on women and health has found that women are contributing around $3 trillion to global health care, but nearly half of this (2.35% of global GDP) is unpaid and unrecognised.

Published in The Lancet, the Commission offers one of the most exhaustive analyses to date of the evidence surrounding the complex relationships between women and health, and demonstrates that women's distinctive contribution to society is under-recognised and undervalued—economically, socially, politically, and culturally.

The report underlines that women are important providers as much as recipients of health care, and that globally, their changing needs in both of these respects are not being met.

According to Professor Ana Langer, head of the Women and Health Initiative at Harvard T. H. Chan School of Public Health in Boston, USA, who co-led the commission, "Too often, women's health is essentially equated to maternal and reproductive health. However, the evidence outlined by this Commission overturns this conventional interpretation, and we urge the global health community and policymakers worldwide to embrace a more holistic – and realistic – understanding of women and health. It's time to acknowledge women's comprehensive health needs throughout their lives, and their productive contributions to health care and society as a whole, as well as their similarly important roles as mothers and homemakers."

The Commission, which brought together leading thinkers, heads of programmes, and activists from around the world, examines the complex links between biological, economic and social factors in improving women's health throughout their lives – including the substantial effects of rapid globalisation, urbanisation, and climate change, all of which have inequitable effects on women's health.

According to Professor Afaf Meleis from the University of Pennsylvania School of Nursing, Philadelphia, USA, who co-led the Commission with Langer, "Often urban areas are developed without any input from women, and without addressing their needs for adequate lighting, safe transportation, access to healthy food, to infrastructures that promote community connectivity, and to integrated health care, child and elderly care. This puts women at increased risk of violence, non-communicable diseases and stressful life overload, which may in turn have adverse consequences for their families."

Tuesday, December 15, 2015

A national campaign for electronic health records is driving business for at least 20 companies with thousands of workers ready to help stressed doctors log the details of their patients' care – for a price. Perhaps 1 in 5 physicians now employ medical scribes, many provided by a vendor, who join doctors and patients in examination rooms. They enter relevant information they hear about patients' ailments and doctors' advice in a computer, the preferred successor to jotting notes on a clipboard as doctors universally once did.

The U.S. has 15,000 scribes today and their numbers will reach 100,000 by 2020, estimates ScribeAmerica, the largest competitor in the business. After buying three rivals this year, it employs 10,000 scribes working in 1,200 locations.

Regulation and training are not rigorous. Scribes are not licensed. About a third of them are certified and that's voluntary, according to the sole professional body for scribes. The American College of Scribe Specialists was created by ScribeAmerica's founders in 2010.

"This is literally an exploding industry, filling a perceived gap, but there is no regulation or oversight at all," says George Gellert, regional chief medical informatics officer at Christus Santa Rosa Health System in San Antonio, which uses scribes.

Others suggest that scribes can be a benefit to doctors and patients by shouldering the minutia of recording many of the details on a computer. "They're capturing the story of a patient's encounter – and afterword, doctors make sure everything is accurate. That way the doctor can focus on interacting with the patient and give them good bedside manner," says Angela Rose, a director at the American Health Information Management Association, a professional group that has published a set of best practices for scribes.

Sunday, December 13, 2015

When I was doing my medical training nearly 20 years ago, there were two kinds of residents: those who were planning on specializing in oncology and those who couldn't tolerate the subject for even a month. One night when I was on call, I worked with someone in the second camp. He told me about a patient of his, an elderly woman with pancreatic cancer that had grown into her bile duct and metastasized through her intestinal tract. She had been through several rounds of ­chemotherapy without success and was ready to quit treatment, but was afraid to tell her oncologist. "She told me, 'I don't want him to think I'm giving up,' " my colleague said, obviously disgusted that she didn't feel comfortable speaking freely about her goals.

He encouraged her to choose hospice care. Two weeks later, he said to me, his patient's hospice aide came up to him on the ward. "She told me that my patient made her promise that the day she died, she would come find me and tell me. She said my patient wanted to thank me for encouraging her to die the way she wanted to."

I thought of this story at various points while reading "The Death of Cancer," Vincent DeVita Jr.'s fascinating if hubristically titled new book, co-authored with his daughter, Elizabeth DeVita-Raeburn, a science writer. Today, more than four ­decades after President Nixon declared war on cancer and with so many new weapons in our arsenal supported by big budgets and a decidedly aggressive posture, when is it O.K. to give up? When is it best to ­surrender?

I'm a doctor with a miracle drug. Three of them, in fact. Their names are Avastin, Lucentis and Eylea. I use them to treat the number one cause of blindness in Americans over sixty-five: wet age-related macular degeneration (AMD). Calling them a miracle is no understatement. If your doctor delivers the unlucky news that you've developed wet AMD, it means blood vessels under your macula have started to leak or bleed, robbing you of the sight you rely on to read books, see faces, watch TV or drive.

Enter the miracle drugs—eye injections that limit those leaking submacular vessels, giving us our first treatment capable of bringing vision back. But somehow, these drugs have become among the most controversial in all of medicine.

All three treat wet AMD very effectively. Their most significant difference is cost. Lucentis and Eylea cost approximately $2,000 and $1,850 per dose, respectively. Avastin? Only $50.

Medicare covers them all, so retina doctors and their patients are free to choose whichever medication they wish. A recent survey of our field showed that 64.3 percent of us choose Avastin as our first-line drug. Yet about 35 percent of retina specialists continue to use the expensive medicines as their first treatment of choice. Why?

Most likely, because they feel these drugs are better than Avastin. After all, we're taught to adhere to the ethical duty to "treat patients the way we'd treat our mothers, or ourselves," right? That's a mental check of ethics I employ during virtually every patient visit, every single day.

But what if, in addition to an ethical duty to do what we feel is best, we also had an ethical duty to recommend the most cost-effective care?

Saturday, December 5, 2015

A hostile letter from a reader made me stop and think about the torments of waiting that cancer patients endure: waiting for a doctor, waiting for radiation, waiting for the delivery of chemotherapy drugs, waiting through interminable infusions or transfusions, waiting for a scan or a biopsy, waiting for the results of a scan or a biopsy, waiting (sometimes starved and unclothed on a gurney in a hall) for surgery.

The email arrived the day after an essay I had written on cancer language appeared online. Without a salutation, it began, "I hate what I've read by you. Simple as that. Your style is dark and nasty." Let's just say that it did not get any better after that.

But toward the end my correspondent stated, "last week I needed to have a thoracentesis for a large pleural effusion" after a seven hour wait in an emergency room. "That's a serious systemic issue," she emphasized, especially for someone with metastatic disease and a shut-down lung who is forced "to sit five hours, then lie on a stretcher for two more and finally be transferred to a real bed at 4 a.m."

From this account, which triggered memories of my own experiences in the ER, I could interpret her fury at me as anger deflected from its primary source: distress at her condition and at having had to wait so long under such frightful circumstances.

Policy makers continue to believe that the problem is people's lack of knowledge that they are wolfing down calorie-rich foods. It is assumed that once Americans know what they are eating, they will eat less, or at least with health in mind. For this reason, many health advocates have called for restaurants to provide people with calorie counts of what they are ordering. Recent mandates mean that by the end of next year, calorie labeling will be required on all menus in chain restaurants and establishments selling food in the United States.

Because many restaurants are already trying menu labeling, we can look at how they have worked, or haven't, and begin to predict how this widespread regulation might function. For instance, researchers looked at data from 66 of the largest chains — those that posted calories and those that didn't — and found that average calories per item were 139 calories lower in restaurants that posted their nutritional information.

Tuesday, December 1, 2015

Measuring blood pressure seems so straightforward. Stick your arm in a cuff for a few seconds, and there they are: two simple numbers, all the information you need to know whether you are in a healthy range or high enough that you should be taking one of the many cheap generic drugs that can bring down your blood pressure.

But the reality is more confusing, as I discovered recently when I tested mine.

It turns out that blood pressure can jump around a lot — as much as 40 points in one day in my case — which raises the question of which reading to trust.

Ever since I wrote about a woman who was in denial about her high blood pressure until she had a stroke, I have been worried that my blood pressure might creep up without my knowing it. I became interested again when I reported that a large federal study of people at high risk for a heart attack or stroke found that bringing blood pressure well below the current national guidelines — a systolic blood pressure below 120 millimeters of mercury instead of 140, or instead of 150 for people older than 60 — significantly reduced the death rate and the rate of heart attacks, strokes and heart failure. The results were so compelling that guideline committees are expected to revise their recommendations.

A week after that study was published, I decided to check my blood pressure with a home monitor before a coming physical examination. The first night, I was startled to find that my systolic pressure was a scary 137. The next night, it was only 117. The next morning, before I saw my doctor, it was a terrifying 152. At the doctor's office, it was 150. I measured it again that night, and it had plummeted to 110. And my diastolic pressure, the lower number, was a rock-bottom 60 that evening.

It seemed unreal. Did I have hypertension because my pressure had hit 152 in the morning? But if I took a drug to bring it down, what would happen if my pressure was trying to go down to 110 in the evening?

I asked a few experts.

"Short answer is, you are normal," said Dr. David McCarron, a research associate at the University of California, Davis, adding that anyone whose pressure goes down to 120 or, in my case 110/60, does not have hypertension. His advice to patients is to abstain from obsessively monitoring their blood pressure.

South Asians today account for more than half of the world's cardiac patients. Heart disease is the leading cause of death in India, Pakistan and Bangladesh, and rates have risen over the past several decades. South Asian immigrants to the United States, like me, develop earlier and more malignant heart disease and have higher death rates than any other major ethnic group in this country.

The reasons for this have not been determined. Traditional cardiac risk models, developed by studying mostly white Americans, don't fully apply to ethnic communities. This is a knowledge gap that must be filled in the coming years. Fortunately, there is a model for doing so: research performed in a small town in Massachusetts over the past seven decades. Known as the Framingham Heart Study, it is perhaps the most influential investigation in the history of modern medicine.

The Framingham Heart Study is a big reason we have achieved a relatively mature understanding of heart disease in the United States — at least for a large segment of our population. It established the traditional risk factors, such as high blood pressure, diabetes and cigarette smoking, for coronary heart disease. Framingham also spearheaded the study of chronic noninfectious diseases in this country, and indeed introduced many doctors to the very idea of preventive medicine.

The impetus for Framingham was clear. In the 1940s, cardiovascular disease was the main cause of mortality in the United States, accounting for nearly half of all deaths. Knowledge of coronary risk factors was spare. As Dr. Thomas Wang and colleagues wrote in the journal Lancet last year, "Prevention and treatment were so poorly understood that most Americans accepted early death from heart disease as unavoidable."

As the chairman of the neurosurgery department at the University of California at Davis, Paul Muizelaar saw patients on Wednesdays, at a clinic housed in a former cannery in East Sacramento. Among the people waiting to see him on the afternoon of November 10, 2010, was Terri Bradley, a fifty-six-year-old woman on whom he had operated the previous May, to remove a malignant brain tumor the size of a lime. Sitting in his office, Muizelaar reviewed Bradley's file. He read a letter from her oncologist, asserting that Bradley was doing well: a brain scan had found no evidence of the tumor. "I think, This sounds great," Muizelaar, a sixty-eight-year-old Dutchman, recalled. "So I go to her exam room with a big smile on my face, and there she is with her daughter, crying, not able to speak."

Muizelaar hadn't seen Bradley's latest test results. Her condition had suddenly deteriorated, and new scans revealed that her tumor—a deadly type known as glioblastoma multiforme, or GBM—had returned. It had spread from the right side of her brain to the left frontal lobe, acquiring an ominous winged shape that doctors refer to as a butterfly glioma. A second tumor had sprouted in the region of her brain associated with speech. Bradley, partially paralyzed and dependent on a wheelchair, had already undergone chemotherapy and radiation; her doctors believed that more drugs were pointless. "The radiologist said, 'I've never seen anything grow so fast,' " Bradley's daughter Janet recalled. "He said, 'Call hospice.' That scared the hell out of me."

Bradley, a fiercely self-reliant woman who had raised four daughters on her own, refused hospice care. Finally, Janet took her to Muizelaar, who said that he was unable to help. "It's a blessing to most patients not to linger," Muizelaar, who practiced medicine in California under a license reserved for eminent foreign-trained physicians, told me. "Within four weeks, this woman had regrown a massive tumor, plus a second tumor. There was clearly nothing I could do about it."

Yet the conversation did not end there. An hour before Bradley's appointment, Muizelaar had received tantalizing news about a patient on whom he had performed an exceedingly unusual procedure. The previous month, he had operated on Patrick Egan, a fifty-six-year-old real-estate broker, who also suffered from glioblastoma. Egan was a friend of Muizelaar's, and, like Terri Bradley, he had exhausted the standard therapies for the disease. The tumor had spread to his brain stem and was shortly expected to kill him. Muizelaar cut out as much of the tumor as possible. But before he replaced the "bone flap"—the section of skull that is removed to allow access to the brain—he soaked it for an hour in a solution teeming with Enterobacter aerogenes, a common fecal bacterium. Then he reattached it to Egan's skull, using tiny metal plates and screws. Muizelaar hoped that inside Egan's brain an infection was brewing.

Muizelaar had devised the procedure in collaboration with a young neurosurgeon in his department, Rudolph Schrot. But as the consent form crafted by the surgeons, and signed by Egan and his wife, made clear, the procedure had never been tried before, even on a laboratory animal. Nor had it been approved by the Food and Drug Administration. The surgeons had no data to suggest what might constitute a therapeutic dose of Enterobacter, or a safe delivery method. The procedure was heretical in principle: deliberately exposing a patient to bacteria in the operating room violated a basic tenet of modern surgery, the concept known as "maintaining a sterile field," which, along with prophylactic antibiotics, is credited with sharply reducing complications and mortality rates. "The ensuing infection," the form cautioned, "may be totally ineffective in treatment of the tumor" and could cause "vegetative state, coma or death."

Tuesday, November 24, 2015

Sturdy legs could mean healthy brains, according to a new study of British twins.

As I frequently have written in this column, exercise may cause robust improvements in brain health and slow age-related declinesin memory and thinking. Study after study has shown correlations between physical activity, muscular health and mental acuity, even among people who are quite old.

But these studies have limitations and one of them is that some people may be luckier than others. They may have been born to have a more robust brain than someone else. Their genes and early home environment might have influenced their brain health as much as or more than their exercise habits. Their genes and early home environment also might have influenced those exercise habits, as well as how their bodies and brains responded to exercise.

In other words, genes and environment can seriously confound experimental results.

That problem makes twins so valuable for scientific purposes. (Full disclosure, I am a twin, although not an identical one.) Twins typically share the same early home environment and many of the same genes, and if they are identical, all their genes are the same.

So if one twin's body, brain and thinking abilities begin to differ substantially over the years from the other's, the cause is less likely to be solely genetic or the early environment, and more likely to be attributable to lifestyle, including exercise habits.

Sunday, November 22, 2015

If you've ever tried out the latest diet fad only to find yourself gaining weight and feeling awful and wondered what you were doing wrong, scientists now have an explanation for you.

Israeli researchers, writing in the journal Cell this week, have found that different people's bodies respond to eating the same meal very differently — which means that a diet that may work wonders for your best friend may not have the same impact on you.

Lead authors Eran Segal and Eran Elinav of the Weizmann Institute of Science focused on one key component used in creating balanced diet plans like Atkins, Zone or South Beach. Known as the glycemic index or GI for short, it was developed decades ago as a measure of how certain foods impact blood sugar level and has been assumed to be a fixed number.

But it's not. It turns out that it varies widely depending on the individual.

The researchers recruited 800 healthy and pre-diabetic volunteers ages 18 to 70 and collected data through health questionnaires, body measurements, blood tests, glucose monitoring and stool samples. They also had the participants input lifestyle and food intake information into a mobile app that ended up collecting information on a total of 46,898 meals they had.

Each person was asked to eat a standardized breakfast that included things like bread each morning.

They found that age and body mass index, as expected, appeared to impact blood glucose level after meals, but so did something else. Different individuals showed vastly different responses to the same food, even though their own responses remained the same day to day.

Pretty regularly, I receive an urgent call from a distraught friend or friend of a brother. "Zeke, Mom was at home and her heart stopped. The E.M.T.s are rushing her to XYZ hospital in Miami. Can you help me find the best cardiologist there for her?"

"Get me the best cardiologist" is our natural response to any heart problem. Unfortunately, it is probably wrong. Surprisingly, the right question is almost its exact opposite: At which hospital are all the famous, senior cardiologists away?

One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away.

Saturday, November 21, 2015

When should a doctor betray a patient's confidence? This week the Supreme Court of the State of Washington heard arguments on this question in a case that has profound implications for the doctor-patient relationship.

In the case, Volk v. DeMeerleer, a psychiatrist, Howard Ashby, was sued after a patient of his, Jan DeMeerleer, shot and killed an ex-girlfriend and her 9-year-old son before killing himself. (Mr. DeMeerleer also stabbed another son, who survived.) The estate of the victims, Rebecca and Phillip Schiering, took legal action, arguing that Dr. Ashby was liable because he had not warned the Schierings. A lower court ruled in Dr. Ashby's favor on the grounds that Mr. DeMeerleer, who had occasionally voiced homicidal fantasies, had made no specific threats toward the Schierings during his treatment.

But last November an appeals court reversed that judgment, asserting that doctors could be required to warn "all foreseeable victims" of potentially dangerous patients in their care. Whether the attack on the Schierings was foreseeable, the court said, should be decided by a jury.

Though the murder of innocents is obviously a tragedy, the Washington State Supreme Court should overturn the appeals court's decision. Not only does that judgment greatly expand the circumstances in which psychiatrists would be required to violate patients' confidentiality; those violations in the end would also not serve the purpose for which they were intended.

Throughout history, doctor-patient confidentiality has been a cornerstone of Western medical practice. The duty to keep patients' information private is written into the codes of ethics of medical organizations, and is even in the Hippocratic oath: "What I may see or hear in the course of treatment," it says, "I will keep to myself."

Thursday, November 19, 2015

Jacqueline Stokes spotted the home paternity test at her local drugstore in Florida and knew she had to try it. She had no doubts for her own family, but as a cybersecurity consultant with an interest in genetics, she couldn't resist the latest advance.

At home, she carefully followed the instructions, swabbing inside the mouths of her husband and her daughter, placing the samples in the pouch provided and mailing them to a lab.

Days later, Stokes went online to get the results. Part of the lab's Web site address caught her attention, and her professional instincts kicked in. By tweaking the URL slightly, a sprawling directory appeared that gave her access to the test results of some 6,000 other people.

The site was taken down after Stokes complained on Twitter. But when she contacted the Department of Health and Human Services about the seemingly obvious violation of patient privacy, she got a surprising response: Officials couldn't do anything about the breach.

Wednesday, November 18, 2015

In a battle against an infection, antibiotics can bring victory over enemy germs. Yet that war-winning aid can come with significant collateral damage; microbial allies and innocents are killed off, too. Such casualties may be unavoidable in some cases, but a lot of people take antibiotics when they're not necessary or appropriate. And the toll of antibiotics on a healthy microbiome can, in some places, be serious, a new study suggests.

In two randomized, placebo-controlled trials of healthy people, a single course of oral antibiotics altered the composition and diversity of the gut microbiome for months, and in some cases up to a year. Such shifts could clear the way for pathogens, including the deadly Clostridium difficile. Those community changes can also alter microbiome activities, including interacting with the immune system and helping with digestion. Overall, the data, published Tuesday in the journal mBio, suggests that antibiotics may have more side effects than previously thought—at least in the gut.

In the mouth, on the other hand, researchers found that microbial communities fared much better, rebounding in weeks after antibiotic treatments. The finding raises the question of why the oral microbiome is less disturbed by drugs. It could simply be because of the way that antibiotics, taken orally, circulate through the body. Or, it could imply that oral microbiomes are innately more resilient, a quality that would be useful to replicate in microbial communities all over the body.

Young American adults own smartphones at a higher rate than any other age group. And researchers from Duke University wanted to see if capitalizing on that smartphone usage with a low-cost weight-loss app might help the 35 percent of young adults in the U.S. who are overweight or obese.

If you're rooting for smartphones to solve all our health problems, you're not going to like what the researchers found. The smartphone app didn't help young adults lose any more weight than if they hadn't been using the app at all.

The study, published in the journal Obesity, looked at 365 young adults ages 18-35. A third of the participants used an Android app specifically created for the study, which not only tracked their calories, weight and exercise but also offered interactive features such as goal setting, games and social support.

Another third of the participants received six weekly personal coaching sessions, followed by monthly phone follow-ups. Plus, this personal coaching group was also encouraged to track their weight, calories and exercise via smartphone.

The last third of the participants were given three handouts on healthy eating and exercise – nothing else.

Researchers tracked the young adults' progress after six months, one year and two years. The personal coaching group had lost more weight than the other two groups after six months, but that lead vanished at the one- and two-year follow-ups.

As for the group using the smartphone app, their average weight loss was never more than the other two groups.

Lead author Dr. Laura Svetkey said she and her colleagues were both surprised and disappointed at the results.

"Given the seeming power of cellphone apps and frankly the popularity of these health and fitness apps in the commercial world, we thought this might be a really good strategy to provide effective intervention very broadly and potentially at low cost," said Svetkey, a professor of medicine at Duke University School of Medicine.

Yet, Svetkey says, it's difficult to get the same level of intensity in an app that you might get through personal coaching, and people have the tendency to stop using weight-loss apps after a while.

Fewer men are being screened for prostate cancer, and fewer early-stage cases are being detected, according to two studies published Tuesday in The Journal of the American Medical Association.
The number of cases has dropped not because the disease is becoming less common but because there is less effort to find it, the researchers said.

The declines in both screening and incidence "could have significant public health implications," the authors of one of the studies wrote, but they added that it was too soon to tell whether the changes would affect death rates from the disease.

Research shows that people who keep track of what they eat and weigh on a regular basis are more likely to succeed at losing weight and keeping it off. But as the food diary of Steve Lochner shows, food tracking and weight loss is far from simple.

In February of 2012, he weighed a high of 337 pounds. But then he started tracking his eating habits using the Lose It food tracking app. Soon he became a "Super Tracker," detailing virtually every bite of food — good and bad — that he ate over a three-year period, losing more than 100 pounds. Here's how he did it.

Tuesday, November 17, 2015

Ruth Dreifuss is former President of Switzerland and Minister of Home Affairs. Anand Grover is former U.N. special rapporteur on the Right to Health, India. Michel Kazatchkine is former executive director of the Global Fund to fight AIDS, Tuberculosis and Malaria. The opinions expressed in this commentary are theirs.

Millions of people are dying in pain because of the repressive stance the world has taken on drugs. That's because states are obsessed by the fear that people will use controlled medicines such as morphine as recreational drugs, thereby neglecting their important medical uses.

Where you live determines whether you will be able to access to controlled medicines, particularly opiates, when confronting an acute terminal, chronic or painful illness. Ninety-two per cent of the world's morphine is consumed by only 17% of the world's population, primarily the United States and Europe. Seventy--five percent of the world's people in need do not have access to pain relieving medicine.

In other words, most of the global population, outside the affluent countries in the North, dying in pain, including from terminal cancers, do so in the absence of dignified palliative care.

This is a horrendous situation for millions of patients and families. Essential medicines such as morphine, taken for granted as the standard relief of severe pain in the global North, do not enjoy the same status in the global South. Quite the opposite. Chances are, if a person living in any developing country ends up with an illness associated with extreme and avoidable pain, they will endure the pain simply because their government has created obstacles to morphine use in hospitals.

Once personal health technology meant little more than bathroom scales, thermometers and electric toothbrushes. Now, these devices and apps are everywhere: on our wrists, in our phones, the bedroom, the kitchen, even on our children and pets. In this special issue of Science Times, we explore the lives of newly wired consumers and the consequences, good and bad, that arise from our increasing reliance on trackers, monitors, guides and a vast array of other devices to better our health.

Antibiotic resistance, which can turn common ailments into killers, has reached dangerous levels globally, the World Health Organization warned Monday, saying widespread misunderstandings about the problem was fuelling the risk.

Antibiotic resistance happens when bugs become immune to existing drugs, allowing minor injuries and common infections to become deadly.

This happens naturally, but overuse and misuse of the drugs dramatically speeds up resistance, WHO said, voicing alarm at the results of a worldwide study showing that misconceptions about the threat are widespread, prompting dangerous behaviors.

Sunday, November 15, 2015

On a recent afternoon, Ina Vandebroek was poking around the shelves of La 21 Division Botanica on the Grand Concourse in the Bronx. Its narrow aisles were crammed with thousands of votive candles, herbal potions and brightly colored plaster statues of saints.

Dr. Vandebroek, a Belgian-born ethnobotanist, paused to gaze at herb-infused oils. The vials had names like Amor Prohibido ("Forbidden Love"), for those in search of adventure, and Conquistador, for the timid — both of them big sellers. Bendicion de Dinero Al Hogar ("A Blessing for Money in the House"), which comes in a spray, is also popular. But Dr. Vandebroek was not there to jump-start a flagging love life or curry the favor of spirits. La 21 Division is a regular stop for her, a mile or so from her laboratory at the New York Botanical Garden, where she is the assistant curator of economic botany.

She is conducting a multiyear study of the folk remedies sold in New York's botanicas, more than 100 emporiums that offer products for all that ails the body, mind and soul to a clientele mainly consisting of Latino and Caribbean immigrants. She is compiling guides in English and Spanish describing the plants and their uses. Her goal is to promote "culturally effective and sensitive health care" for a community that is chronically underserved by mainstream medicine.

I have 15 minutes. I'm generally not happy that, as an internist who works for a large medical group (most of us do now), I'm instructed to conform to this assigned length for visits with my patients. Being told to arrive at 2:45 p.m. makes it clear to patients that every doctor-hour is broken into quarters. But the pressure to keep to the time limit is felt primarily by the doctor, who must stick to the schedule or expect the 3 p.m. patient to come in unhappy about the wait.

A patient in any medical practice rightly wants the visit to take as long as is reasonably required. A healthy 25-year-old with a sore throat is thrilled to be out of my office in less than 10 minutes, after a focused exam and a culture. Most patients, though, don't present a single problem that can be addressed with a targeted answer. The 15-minute visit shortchanges those patients while frustrating the doctors who want to help make them well.

Marvin is thin, 6-foot-4, a 36-year-old commercial mortgage broker with a lineless, hard-to-read face. I've seen him once before, 11 months earlier, so this is considered a follow-up visit, half the length of a 30-minute first encounter.

There's a typical sequence to a 15-minute visit. In the opening phase, researchers who have studied primary-care interactions expect that I would "establish a cordial atmosphere" and "convey interest," and in fact I talk to Marvin about the Yankees' pitching problems. In the history section, I gather data with yes/no questions and tell-me-more-about-that follow-ups. "My back's acting up," Marvin says. Back pain is one of the 10 most common patient complaints in primary care and is almost never life-threatening. This shouldn't take very long if I'm clinically efficient and a clear communicator. Still, I try not to show that I am in a hurry. I do not wear a watch. Did your back pain begin after an injury? I ask. Have there been pain-free days? Are there certain positions or medications that have afforded relief? "It's been bad the past couple of months," Marvin says.

Saturday, November 14, 2015

Dave Asprey does not like infomercials. He didn't want our conversation to feel like one, he said, raising both hands in a gesture of innocence, like a magician showing there was nothing up his sleeve. But once he planted the suggestion, it wouldn't go away. There was the register of his voice, oscillating between breathy and enthusiastic, and the complete absence of qualifiers to soften his bold claims. And then there were the wares clustered on the table in front of him. He had laid out cups of his signature product, Bulletproof Coffee, which is made with grass-fed butter and Brain Octane, a trademarked oil extracted from coconuts. Next to the cups lay Bulletproof-branded protein bars in chocolate and vanilla. ''I am not plugging my stuff,'' he said with a semi-embarrassed laugh. ''I'm just talking about how things work.''

And this is how things work for Asprey, according to his claims: By experimenting on his own body, he found a diet to end all diets, one that encourages the consumption of rich foods like avocado, steak and butter and requires little exercise to maintain a healthy weight. In the course of developing this diet — the Bulletproof Diet — Asprey says he lost 100 pounds, boosted his I.Q. more than a dozen points and lowered his biological age in the process.

Friday, November 13, 2015

Since Apple introduced its ResearchKit software in March, scientists at leading medical schools across the country have written apps to study asthma, Parkinson's disease, autism, epilepsy, melanoma, breast cancer and other ailments. Medical experts are hopeful that using smartphones to gather health data from millions of people, with their consent, can open a window to new insights into diseases, treatments and lifestyle effects.

The Apple move was a breakthrough, but a gap remained. "You can't just do research studies on people who can afford iPhones," said Deborah Estrin, a professor of computer science at Cornell Tech in New York.

Shortly after Apple introduced ResearchKit, Ms. Estrin, who is also a professor of public health at Weill Cornell Medical College, started trying to bring similar capability to the other major smartphone software platform, Google's Android. She coordinated the work on a new initiative, ResearchStack, announced on Thursday.

The new software framework will be similar to ResearchKit, which is open source and designed as modular building blocks. The ResearchStack design work is being led by Cornell Tech; Touch Lab, an Android developer; and Open mHealth, a nonprofit start-up focused on software for sharing health data. ResearchStack is being funded by the Robert Wood Johnson Foundation.

ResearchStack is intended to work smoothly with research projects underway that use Apple's ResearchKit. "Researchers can create a study that is independent of what smartphone is used, and they won't have to start from scratch," said Ms. Estrin, who is also co-founder of Open mHealth.

One of the current projects ResearchStack will soon support is Mole Mapper, an app for a melanoma study developed by the Oregon Health and Science University. The melanoma study involves people taking smartphone pictures of moles at regular intervals to track their growth, with the goal of creating detection algorithms and helping people manage the health of their skin.

The key to successful apps for large-scale studies, Ms. Estrin said, is to develop them for individuals as well as researchers. People, she said, have to control their health data and find it personally useful. That is what will fuel "the growing data-sharing movement," she said, prompting millions of people to "contribute to big-data-derived discovery and understanding" in medicine.

Thursday, November 12, 2015

The Literature, Arts and Medicine Database (LitMed) is a collection of literature, fine art, visual art and performing art annotations created as a dynamic, comprehensive resource for scholars, educators, students, patients, and others interested in medical humanities. It was created by faculty of the New York University School of Medicine in 1993. The annotations are written by an invited editorial board of scholars from all over North America.

We define the term "medical humanities" broadly to include an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, multimedia and visual arts) and their application to healthcare education and practice. The humanities and arts provide insight into the human condition, suffering, personhood, and our responsibility to each other. They also offer a historical perspective on healthcare. Attention to literature and the arts helps to develop and nurture skills of observation, analysis, empathy, and self-reflection -- skills that are essential for humane healthcare. The social sciences help us to understand how bioscience and medicine take place within cultural and social contexts and how culture interacts with the individual experience of illness and the way healthcare is practiced.

Wednesday, November 11, 2015

Cincinnati - The heroin problem in Ohio is now getting attention from the Centers for Disease Control and Prevention.

The federal agency has been asked to come here and help find answers to a disturbing new trend that is costing lives – heroin mixed with a prescription pain medication.

State and local health experts said they are hoping what they learn during meetings Tuesday at the Hamilton County Board of Health will help them tackle the heroin crisis.

The CDC has a six-person team on the ground in Ohio, meeting with the Ohio Department of Health, and the Hamilton County Health Department.

Officials said they're focusing on a particular part of the heroin crisis – the number of deaths related to fentanyl.

Authorities said fentanyl is a prescription pain medication that has been showing up in heroin. The big mystery is why it's being mixed with heroin.

"We don't fully understand the fentanyl situation, and that's one of the reasons we wanted their help with this," said Dr. Mary DiOrio, the medical director of the Ohio Department of Health.

ODH asked the CDC to help look into the problem.

"We think that some people don't even know that it's in what they're injecting so we're trying to fully understand what people do and don't know so we can target the messages appropriately so we can protect lives," DiOrio said.

We've seen the deadly consequences of fentanyl in Greater Cincinnati.

Kenneth Gentry is facing charges in the overdose death of an Arlington Heights man earlier this year that was blamed on fentanyl.

Authorities said the fentanyl problem causes only a fraction of the deaths heroin alone causes – but it's a problem that's growing quickly.

Authorities said heroin deaths increased 18 percent in Ohio last year to a total of nearly 2,500. In 2014 there were about 500 deaths linked to fentanyl – an increase of nearly 600 percent from the year before.

There has been an alarming and steady increase in the mortality rate of middle-aged white Americans since 1999, according to a study published last week. This increase — half a percent annually — contrasts starkly with decreasing death rates in all other age and ethnic groups and with middle-aged people in other developed countries.

So what is killing middle-aged white Americans? Much of the excess death is attributable to suicide and drug and alcohol poisonings. Opioid painkillers like OxyContin prescribed by physicians contribute significantly to these drug overdoses.

Thus, it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality. The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.

You may not know it, but you could be on the hook to pay at least $124 this year for a drug you probably don't take.

The drug is a new class of cholesterol-lowering agents called PCSK9 inhibitors. Its cost and how we are paying for it illustrate why we all need to care about not only our own health care bills but also those of our neighbors. And it helps focus the debate about drug prices on two questions: What is the value delivered by the drug, and can that be linked to its price? And how should such value-based prices be implemented?

In July, the Food and Drug Administration approved the first of two new PCSK9 inhibitors that lower the bad type of cholesterol, LDL. Studies suggest that they can reduce it by up to 60 percent, compared with a placebo, and reduce it up to 36 percent more than statins and a drug called ezetimibe. However, there are no definitive data on how much these drugs actually reduce heart attacks, strokes and deaths from heart disease. Researchers suggest they might decrease the likelihood of such bad outcomes. For example, one preliminary study found that taking the drug lowered the overall chances that a patient would experience a heart attack or stroke, or hospitalization or death from heart disease, to 1.7 percent from 3.3 percent. The definitive studies will be out in 2017.

Drugs like these can help us lead longer, more productive lives. The problem is that the companies producing these drugs — Amgen, Sanofi and Regeneron — announced that the retail price for a prescription would be more than $14,000 per patient per year. The price is particularly steep given that these drugs may need to be taken for the rest of the patients' lives. How much patients pay directly would depend on their insurance plan.

When the stock market crashed in 2008, my wife and I were 70. And we saw half of our retirement funds disappear. Before the crash, we felt secure in the belief that we had enough money to last as long as we lived; after the crash, we feared that we would not, and I worried about it a great deal. I had a hard time going to sleep and an even harder time going back to sleep after getting up to go to the bathroom in the middle of the night. I came to hate going into that bathroom because I knew my demons resided there and would invade my consciousness immediately.

By the time the stock market began to recover and our savings were again at a comfortable level, I had become conditioned to associate my nightly bathroom trips with "worry time." I would worry about everything: home repairs, trip planning, medical issues and all the vicissitudes of old age, fears of infirmity, dying and seeing my friends and loved ones die.

One night two weeks ago, for the first time in seven years, I realized that the worry demons had not appeared and that I had gone several days without hearing from them. This was a direct result, I believe, of changes that I made to my life over the previous two months. My tools consisted of a tiny amount of the tranquilizer clonazepam and three concurrently undertaken therapies, all new to me: psychological therapy, awareness meditation and religion. I call religion new in the sense that I had pretty much stopped believing in God when I was 20 years old. I call it a therapy because it helped to heal what ailed me.

My call to action began one evening when my blood pressure reached 199. For the previous six months my blood pressure had been jumping around. I had started monitoring it myself with a home machine. For two weeks I would take my blood pressure, meditate, check it again, meditate more, etc. At first, I was able to correlate a finding that proved to me that my blood pressure dropped after meditating, but on this night the numbers went the other way. My blood pressure increased after meditating and I panicked. I checked it repeatedly until it hit 199. I rushed to the bedroom and told my wife that she might have to call 9-1-1. She recommended that I take a Xanax, lie down and try to relax, and for God's sake stop taking my blood pressure. (She has since hidden my machine.)

The next morning we saw our family doctor. He gave me a prescription for clonazepam and said he thought I would be fine. I was more concerned than he was, and I asked if he could recommend a psychologist. Soon I began weekly visits with a clinical psychologist, Dr. Henry Kimmel, in Encino, Calif. I also started meditating regularly for one hour each night, with the aid of a free online service through the Mindful Awareness Research Center at the University of California, Los Angeles. I now had two therapies plus a drug to help arm me against the nighttime attacks in my bathroom.

The patient's blood pressure had reportedly crashed in the ambulance; a gunshot wound had damaged the heart. In the operating room, a medical resident, Dr. Dan Hashimoto, slid a knife into the patient's chest and sliced horizontally, from the sternum across the torso.

He thrust his hand into the gash, grasped the beating heart and squeezed, to the tempo of 100 beats a minute.

Noticing bleeding from the right ventricle, Dr. Hashimoto stopped pumping to sew up the hole. The pulse recovered, and blood pressure climbed.

Concerned there might be more bleeding in the belly, Dr. Hashimoto moved to stop blood flow to the aorta. He struggled a bit to position the clamp.

Yet no one's life had been saved. Dr. Hashimoto, a third-year-resident at Massachusetts General Hospital, had been practicing what is known as an emergency department thoracotomy on a rubber and plastic dummy that — but for the fact that it did not have a head — felt and acted remarkably like a human body.

A new analysis of data from a large national study has found that carrying fat around the middle of the body greatly raises the risk for heart disease and death, even for those of normal weight.

Doctors usually determine obesity by body mass index, or B.M.I. — calculated from height and weight — but the calculation does not distinguish between fat and lean muscle weight. Measuring waist-to-hip ratio presents a different, and possibly more accurate, picture because it accounts for central obesity, or visceral fat, the fat stored around the internal organs.

Waist-to-hip ratio is waist measurement divided by hip measurement. According to the World Health Organization, a ratio higher than .90 for men or .85 for women defines central obesity.

It has been known for some time that having an "apple" shape increases the risk for disease and death. But the new study found that a man of normal B.M.I. with an abnormally large belly has an 87 percent higher risk for death than a man with the same B.M.I. but a normal waist-to-hip ratio. Pot-bellied women of normal B.M.I. have a 48 percent higher risk than women with normal B.M.I. and normal belly fat.